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Margaret A. Swarbrick, PhD, OT, FAOTA; Judith Cook, PhD; Lisa Razzano, PhD, CPRP; Jay Yudof, MS, CPRP; Jen Cohn, BS, CPRP; Christina Fitzgerald, RN, BS; Betty Redman, LPN, CPRP; Maureen Costa; Tina Carter, BA; Karen Burke, MS, CPRP; and Chantelle Yost, BS

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Many individuals with major mental disorders live with medical comorbidities that contribute to poor quality of life and shortened life span (Parks, Svendsen, Singer, Foti, & Mauer, 2006). We con-ducted a study to screen for, identify, and document co-occurring physical health conditions, health risk factors, and use of health care services among individuals served by the public men-tal health system. Through a series of health screenings, we sought to better understand the level of health risks among members of community men-tal health programs in four states by screening for a number of common medical comorbidities including obe-sity, hypertension, diabetes, high cho-lesterol, substance use, nicotine depen-dence, and heart disease. The purpose of this article is to share our observa-tions and experiences during dialogues with health screening participants at the various screening stations that comprised the event. Individuals who staffed the screening stations reflect herein on the experiences, reactions, and dialogues they had with partici-pants to better understand how to help and support their steps toward healthi-er lifestyles and behaviors.

LITERATURE REVIEWCommunity-based health screenings

are useful for stimulating awareness of one’s health, health issues, and risk fac-

tors; increasing awareness of community services and needs (Brown & Khan, 1998); enhancing awareness and educa-tion regarding risk reduction and pre-ventive behaviors; and providing infor-mation to participants that is relevant and culturally competent (Blumenthal & Kahn, 1979; Carter, 1991). Indi-viduals participate in health screenings in an attempt to directly access health information relevant to their own needs (Mess et al., 2000) and potentially carry out subsequent self-directed interven-tions (Blumenthal & Kahn, 1979). Screening events not only provide at-tendees with general health information but also focus on information that is spe-cific to their own personal health risks and conditions (Carter, 1991). Informa-tion gained in health screening events can positively affect participants’ health knowledge. Other information provided generally details illness prevention and healthy living strategies, treatment op-tions, and programs that can assist indi-viduals in health promotion.

The Health Beliefs Model (Rosen-stock, Strecher, & Becker, 1988) posits that both health risks and protective be-haviors are affected by multiple factors, including overall health beliefs, attitudes regarding vulnerability to illnesses, and personal perspectives about illness course and consequences. Participation in health screening events is believed to positively affect health beliefs, including feelings of control over one’s health and lifestyle.

We conceptualized that our health screening events would provide a vehi-cle for initiating dialogues with partici-pants about their health beliefs, health risks, and lifestyle. We also hypothesized that new health and wellness strategies could be stimulated by the screening events, as participants examined their personal health beliefs and attitudes and how these might affect their health sta-tus. Therefore, we structured our health fair to allow for dialogue at each station, along with a specialized peer support station at the end of the screening pro-cess, to help participants consider their beliefs, test results, and improve their ability to take control of their health and decide on the next steps. To further increase participants’ comfort levels, we recruited peers from each agency who we trained and paid to work as health fair greeters and to guide participants from one station to the next. This ar-ticle provides selected anecdotes and conversations that occurred at each station to illustrate the range of partici-pants’ health beliefs and attitudes and how these affected what they believed was possible for them in terms of health behavior change.

METHODParticipants

A total of 457 health screening par-ticipants were recruited from peer-run and non-peer-run mental health pro-grams and attended health screenings held in four states (New Jersey, Illinois, Maryland, and Georgia) from April 2011 through June 2012. The states were selected based on the fact that the university research center was conduct-ing separate individual research studies in specific local areas of those states. Thus, the health screenings were held prior to initiating any research to char-

ABSTRACTNurses can play an important role in community-based health screenings, which are a practical resource to empower people living with mental and substance use disorders to make positive lifestyle changes. The experiences, struggles, and strengths of screen-ing participants provides insights for nurses to engage people in health and wellness dialogues. [Journal of Psychosocial Nursing and Mental Health Services, 51(12), 22-28.]

23Journal of Psychosocial nursing • Vol. 51, no. 12, 2013

acterize the general health condition of people with serious mental illnesses in those local areas of each state. We ap-proached mental health programs in the local areas we had targeted in each of the four states by telephone and e-mail and asked them for their participation. All of the programs contacted in each state agreed to participate. We convened teleconferences with program represen-tatives for 3 months prior to each health fair, during which we discussed plans for advertising the screening, recruiting participants, and logistical matters such as where to hold the event, scheduling and transportation for participants, and how to ship and safely store testing ma-terials and supplies.

This screening study received human subjects approval from the University of Illinois at Chicago Institutional Review Board (IRB) and the IRBs of the col-laborating agencies (Cook et al., 2013. All participants were members of men-tal health treatment, housing, employ-ment, and/or peer support programs. Requirements for participation were age 18 or older, ability to provide informed consent, and ability to participate in the health fair screening stations using spo-ken English.

Approximately half (49%) of the participants were women, with a mean age of 46. Consistent with the man-ner in which the U.S. Census Bureau classifies race and ethnicity, we que-ried participants about each of these classifications separately. Thus, we first asked them whether they considered themselves to be Hispanic or Latino. We next asked them what racial group they belonged to (e.g., Caucasian, Afri-can American, Asian/Pacific Islander). Those who answered the first question affirmatively went on to classify their race as they saw fit. Seven percent said they were Hispanic/Latino. Regard-ing race, 49% identified themselves as White/Caucasian, 39% as Black/Afri-can American, 4% as multi-racial, 2% as Asian/Pacific Islander, and the remain-der as Other. A fifth (20%) had less than a high school education, 31% had a high school diploma or GED, and 49% had some college or a post-secondary degree.

Forty percent were parents, and 8% were currently married or in a cohabiting re-lationship. The large majority received their health insurance through Medic-aid and/or Medicare (78%), whereas rel-atively few had private coverage (10%), veteran’s insurance (2%), or some other form of health insurance (5%). Four-teen percent reported having no health insurance coverage. When asked to share their psychiatric diagnosis, 41% said they had been told that they had schizophrenia, 23% bipolar disorder, 24% depression, 4% anxiety disorder, 1% personality disorder, and 7% some other disorder.

DesignThe authors, who represent the uni-

versity research center and the peer-operated program, designed the health fair collaboratively. Participants moved through a series of 11 stations staffed by members of the health screening team. All individuals who administered health tests or collected research data had to have completed IRB training on federally mandated protections and safeguards of human subjects. All health fair participants were informed of these protections and safeguards and provided written informed consent to indicate that they had received and understood this information. The following is a de-scription of each of the stations.

Welcome and Check-In Station At Station One, participants checked

in, were given information and asked to provide informed consent, and were administered a pre-event survey. This location also provided each participant with a “health passport,” a document they would carry with them throughout the screening so their test results could be recorded and they could then take them home and share with others if they chose. The purpose of the passport was to provide individuals with their screen-ing values (e.g., weight, blood pressure) for both personal management and for sharing with their health care provid-ers. At each of the next seven stations, information was gathered from partici-pants or through a screening activity,

and the test results were given to partici-pants both verbally and on their health passports. Each station also provided in-formational handouts.

Station for Body Mass Index and Waist Circumference

At Station Two, height, weight, and calculated body mass index (BMI) were determined, as well as waist circumfer-ence. These measures are important in-dicators of obesity and indicate possible metabolic syndrome, a risk factor for coronary heart disease, stroke, and type II diabetes (National Heart, Lung, and Blood Institute [NHLBI], 1998).

Stations for Cholesterol and Blood SugarStations Three and Four were locat-

ed together, as both tests required small droplets of blood from participants. This allowed blood to be collected from a single finger stick. Station Three is where the cholesterol levels were taken with the Alere Cholestech LDX® sys-tem using a finger stick blood sample. At Station Four, glycolated hemoglobin (A1C) was measured to identify partici-pant blood sugar level average, using the Bayer A1Cnow® system.

Blood Pressure Station Blood pressure was taken at Station

Five using a blood pressure cuff.

Substance Use StationsAt Station Six, participants were

screened for substance use with the Alcohol Use Disorders Identification Test (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998) and the Drug Abuse Screening Test (Skinner, 1982). Nico-tine dependence was assessed at Station Seven using the Fagerström Test for Nicotine Dependence (Heatherton, Ko-zlowski, Frecker, & Fagerström, 1991).

Station Assessing Risk for Heart Attack At Station Eight, participants were

shown their calculated risk of a heart at-tack in the next 10 years, using the com-puterized Framingham Coronary Risk for Heart Attack website (Wilson et al., 1998). Time was taken at this station to allow individuals to observe the results

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of “what if” calculations that showed the effect of changing one of the algorithm values (e.g., quitting smoking) on reduc-ing participants’ risk.

Station for Peer Support and Check Out Station Nine was the “peer support”

station where peers trained in interpret-ing health risk values and providing peer support reviewed results with par-ticipants and answered their questions. Staff at this station then highlighted potential strategies for addressing health risks outlined on a wellness handout associated with the health passport. Station Ten was designed to allow the data recorded on an individual’s health passport to be entered into the screen-ing project computer database. While this was occurring, participants were asked to complete a post-event survey. Station Eleven, the final station prior to exiting, served as the checkout, where participants received their health pass-port, a gift card to thank them for their time, and a gift bag filled with wellness products and information.

RESULTSThe experiences, challenges, and

strengths shared by screening partici-pants are presented.

Desires and StrugglesAt Station Two, the BMI station,

staff had difficulty calculating waist cir-cumference because the tape measure was not long enough. During the first two health fairs, it was sometimes neces-sary to have participants help, as addi-tional inches had to be added to the 60-inch measuring tape. One young woman at this station said she understood that 60 inches was not a good number, add-ing that she did not need to know the exact width of her waist. She expressed the desire to learn how to reduce her waist size to 60 inches and then decrease the measurement from that point. She said that she struggled with being able to make healthy changes in her diet while also maintaining her active social life, which centered on eating fast food and consuming drinks with little nutritional value (e.g., soda).

Getting on the scale was one of the most difficult tasks for the majority of participants. Staff spent time talking with participants first, to increase their comfort level with stepping on the scale, which many did with reluctance. Sever-al participants had emotional reactions to learning their weight, expressing dif-ficulty with connecting the number on the scale with their own health. One staff member shared her own personal experience of how she had reduced her weight from the morbidly obese to the obese range by taking one step at a time, such as reducing intake of sugary snacks, or replacing soda with water. Many par-ticipants were skeptical that they could make changes in their diets that would have a positive impact on their overall health, citing different factors such as financial and time constraints, or un-willingness to give up foods they found comforting.

Some individuals were unable to be measured by the BMI chart placed on the wall of the station. Either they were too short or too tall, or their BMI was too high to be calculated on the chart, which went up to a BMI of 54 (i.e., av-erage healthy BMI ranges between 18.5 and 24.9 [Centers for Disease Control and Prevention, 2011]). Often, partici-pants did not know where they fell on the chart, and learning their BMI value was disturbing. They would say things such as, “I didn’t know I was that bad,” or “I didn’t realize where I was.” Some-times individuals would talk about how they had tried to lose weight but had given up. Station staff shared their own personal struggles with weight and how weight loss through regular exercise and portion control is possible, which reas-sured participants that it could be done. A few individuals expressed reluctance or embarrassment about going to the gym; therefore, staff suggested low-cost ways they could increase their physical activity, such as daily walking.

Awareness of Personal RisksAt Stations Three and Four, the

nurses who staffed the hemoglobin A1C (HA1C) and cholesterol test stations spent time discussing test results and an-

swering questions. One woman, in her late 20s, was surprised that, although her total cholesterol was normal, her HA1C and BMI readings placed her in the pre-diabetes category. She stated that her HA1C test result was a “wake-up call” and that she was too young to become diabetic. She reported that her mother and several other close relatives had type II diabetes and she was therefore concerned about learning that she was pre-diabetic. However, she also said she had a diet high in processed foods and refined sugars and a sedentary lifestyle. She discussed with health screening staff a plan to make an appointment with her primary care physician to follow up on her test results. Other potential lifestyle modifications were discussed, includ-ing diet and exercise. She also asked for nutrition advice, so information was shared on portion control and adding more fresh fruits, vegetables, and whole grains into her diet. She was a regular soda drinker and said that everyone who lives in her area loves soda. Station staff discussed healthier beverage options in-cluding water, seltzer, and unsweetened iced tea, and also discussed the impor-tance of exercise for keeping glucose lev-els under control. She said she was going to try to add more walking to her daily routine, and staff recommended that she begin slowly with 10 minutes and then gradually work her way up to 30 minutes of exercise per day.

A man in his early 40s stated that he wanted to take part in the health screen-ing because it had been a couple of years since he had had any blood work done. He indicated that he had a “healthy BMI” and exercised regularly, but did not make good food choices on a daily basis. His blood pressure and HA1C results were within normal range, but his total cholesterol was high and his high-density lipoprotein (HDL) (“good cholesterol”) levels were very low. The nurse pointed out that his current cho-lesterol level, in combination with his heavy smoking, placed him at risk for heart disease. He asked for some sugges-tions. The nurse reviewed some of the written materials provided at the station and discussed adding fish to his diet, as

25Journal of Psychosocial nursing • Vol. 51, no. 12, 2013

well as nuts and avocados. Instead of frying foods and cooking with butter, he reported that he planned on trying to cook with olive oil or small amounts of other vegetable oils and would eat fewer processed meats (e.g., bologna, ham, bacon). He stated that he had some knowledge about cholesterol, but appreciated learning more about HDL and low-density lipoprotein levels. He planned to follow up with a physician to determine his need for medication or lifestyle modifications.

Many of the participants whose HA1C results placed them in the pre-diabetic and diabetic ranges reported drinking soda and fruit juice as their main beverage each day. Many people were unfamiliar with the HA1C test and were interested to learn of the existence of a test that could estimate their level of blood sugar control over a 2- to 3-month period. Some expressed the intention of asking for this test from their health care providers in the future.

Lifestyle Habits Can Help Manage Blood Pressure

The reactions of many participants to the blood pressure cuff at Station Five suggested they had some awareness of their typical readings and reasons why these might be high. One participant said, “It’s going to be high, it always is.” Another warned, “It’s high; I forgot to take my medicine this morning.” Oth-ers commented, “I’m stressed,” or “I had a lot of salt today.” Participants offered many reasons for their high blood pres-sure, but not much in the way of strat-egies for corrective action. Staff found it gratifying to be able to provide in-formation and to help individuals un-derstand that medication is a tool, but is never intended to be the only tool to improve the problem of high blood pres-sure. Participants were often unaware that lifestyle changes, not just medica-tion changes, are effective in preventing further damage to the body and related lifelong complications.

HonestyAt Station Six, individuals were will-

ing to be honest about their drinking and

drug use because they were interested in learning whether their current level of use put them at risk for substance abuse or dependence. Staff at this station as-sured participants that their screening results were private by shredding their questionnaires after their risk levels were recorded in their health passports. Many people drank moderately, but some drank as much as a six-pack of beer or a fifth of liquor per day. Others reported smoking marijuana or snorting cocaine. They were surprised to learn about the concept of risk reduction—they did not have to go “cold turkey” and abstain completely from drugs and drinking to gain health benefits. They learned about research showing they could enhance their health just by reducing the amount of drugs or alcohol they consumed each day. Others were interested to learn that treatment for substance use problems has been shown by research to be effective, and that new medications are available to reduce cravings while individuals are trying to quit or reduce their use. One man thanked staff for not lecturing him or trying to make him feel bad for drink-ing. A woman said she was going to at-tend Alcoholics Anonymous.

The Benefits of QuittingAt Station Seven, where nicotine

dependence was assessed, several par-ticipants indicated that they were former smokers. They revealed they had suc-cessfully quit “cold turkey” for various reasons, including declining health and pregnancy. One man shared that he had moved his smoking outside the house when his wife became pregnant. While he weathered outdoor smoking during the pregnancy, he later tired of going out-side to keep the house smoke-free for his infant. Others used ongoing nicotine re-placement to avoid smoking. Two people indicated that they used nicotine patches supplied by a state Medicaid program, but that monthly coverage was for a 4-week supply; therefore, they smoked on the re-maining days of each month.

Surprise and Intrigue: Heart Health Station Eight focused on completion

of a computerized application of the

Framingham Heart Health Risk Indica-tor (Wilson et al., 1998). This comput-erized application considers the effect of multiple health indicators in estimating an individual’s risk for heart attack over the next 10 years, based on his or her sex and age. When participants visited this station, they were interested in how different health and personal factors af-fected heart attack. Although most par-ticipants knew that heart attack risks increase as people age, few were aware that this occurs differently for men and women. Participants were intrigued at how the computer program used their screening results (e.g., triglyceride level, blood pressure) to calculate their heart health. One of the most frequent com-ments was that they liked using the computer application because it showed them how different factors worked to-gether to influence their heart attack risk. For example, one man who was a long-time smoker knew about respira-tory health and lung cancer risks, but did not connect smoking to heart health risks. Participants also learned how bet-ter management of health conditions affected heart health. One woman had been living with diabetes for several years, but was managing it well with diet and medication. As a result, her HA1C value was in the normal range. Staff showed her how her heart health would look if she was not managing her diabetes by plugging in an elevated HA1C value. She expressed surprise at how much her heart attack risk would rise with uncontrolled blood sugar. She also felt proud of being able to use medi-cations and alter eating habits to control her diabetes, and said she was now more determined than ever to stick to these good practices.

Peer Support for Health and WellnessAt Station Nine, peers who had been

trained to provide support for health and wellness offered additional information from the American Heart Association and other organizations. Participants received help understanding their test results and processing the new informa-tion they had received at each station. Many shared stories about struggles with

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KEYPOINTSSwarbrick, M.A., Cook, J., Razzano, L., Yudof, J., Cohn, J., Fitzgerald, C.,...Yost, C. (2013). Health Screening Dialogues. Journal of Psychosocial Nursing and Mental Health Services, 51(12), 22-28.

1. Health screenings were implemented as a strategy to address the health disparity facing individuals with major mental disorders living with medical comorbidities that contribute to poor quality of life and shortened life span.

2. Health screenings were shown to be a viable strategy to empower members of community mental health programs to explore health risks for obesity, hypertension, diabetes, high cholesterol, substance use, nicotine dependence, and heart disease, and wellness strategies to improve health status.

3. Peer supporters were able to engage participants in health dialogues to help empower them in their steps toward healthier lifestyles and behaviors.

Do you agree with this article? Disagree? Have a comment or questions?Send an e-mail to the Journal at jpn@healio.com.

their weight. One individual discussed regular walking as an effective method for weight control. Another reported going regularly to a gym, adding that this was a likely explanation for his nor-mal blood pressure and BMI readings. Many stated they were unaware that they were in the pre-diabetes or diabetes range, as indicated by their HA1C test. A handout with sources of free health care and further testing was provided as follow up, and staff at the station made an effort to talk about what participants could do in the immediate future, using a handout that cross-walked “next steps” for different health risks. For example, participants with high triglycerides were encouraged to eat foods rich in omega-3 fatty acids such as fish, walnuts, and dark leafy green vegetables. Those with high nicotine dependence were informed about new medications for smoking ces-sation and how to discuss these with their physicians. Participants interested in reducing “bad” cholesterol were ad-vised to eat more fruits, vegetables, fish, and nuts and limit fatty meats, egg yolks, and whole milk products.

In addition to providing information, peer supporters discussed participants’ readiness for change to empower and encourage individuals, no matter what their planned course of action or inac-tion. One individual, whose screening indicated he was in the pre-diabetes range, said he was nervous and unsure about what follow-up steps he could take. Staff encouraged him to follow up with his health care provider, gave him a packet of information, and discussed personal wellness and prevention steps, including healthy eating, what healthy eating means, and how to exercise on a limited budget. Some individu-als showed a lack of knowledge about healthy food choices, even those who considered themselves to be “healthy eaters.” When one woman was asked what she meant by healthy eating, she explained that she drank three large fruit smoothies a day, not realizing that these smoothies alone could total more than half of her recommended daily calorie intake. Staff complemented her efforts to improve her diet, and offered educa-

tion regarding smoothies and helped her explore healthy alternatives.

DISCUSSIONDialogues between health fair partic-

ipants and staff at each station revealed that the participants had a range of be-liefs and perceptions about their health and how it was influenced by their overall lifestyles and individual health behaviors. Many participants expressed surprise when informed of their high levels of health risks, and this was some-times accompanied by feelings of con-cern about their ability to make needed changes. Participants were unaware that a common thread to maintaining health and wellness is through fine-tuning strategies such as healthy eating, por-tion control, physical activity, adequate sleep, and regular medical check-ups. Many individuals reported concern about their HA1C ratings, because their parents, grandparents, or siblings had diabetes, yet they had not thought to ask their physicians to perform such a test. The simplicity of the test we used was beneficial because it allowed partici-pants to see within 5 minutes what their average blood sugar had been for the past 90 days. We were able to show them the number value, provide education on what is considered a normal range, and provide them the values in their health

passport along with support and educa-tion so they could connect with their health care providers or supporters.

At the same time, we were impressed at the substantial efforts already being made by some participants to improve their health. Many smokers, for example, had cut back on the number of cigarettes they smoked each day, even though they demonstrated high levels of nicotine de-pendence. It was not unusual for long-time smokers to report cutting back to 5 or 6 cigarettes per day, sometimes aided by the considerable expense associated with smoking incurred by individuals on low incomes. Similarly, many individu-als had been abstinent from drugs and alcohol for a number of years and ex-pressed pride in their ability to maintain their sobriety despite a severe addiction. Still others described efforts to be more physically active, eat healthier, drink more water, develop restful sleep habits, and get regular check-ups. Screening staff drew on these healthy behaviors to provide encouragement to partici-pants who expressed dismay when they learned about health risks of which they had previously been unaware.

We have anecdotal evidence from each of the fairs that some participants were motivated to become more active based on their test results along with the information and support we provided.

27Journal of Psychosocial nursing • Vol. 51, no. 12, 2013

Many participants brought their health passports to appointments with their case managers and agency physicians to share information about their health risks as well as celebrate test results that were positive. Other participants ex-pressed an interest in learning how to conduct their own health screening at their program in the future. They also were intrigued by their interactions with the peers who staffed the health fair. For some, this was their first exposure to peer supporters and they were inspired to think that such a role might be pos-sible for them with the right training and opportunities to reach out to other peers.

NURSING IMPLICATIONSPsychosocial-mental health nurses

play an important role in community-based health screenings. Nurses should staff the blood pressure and blood glu-cose stations and be prepared to provide health education resources and support. It is critical for nurses to be sensitive to the struggles and challenges people living with mental and substance use disorders face as they tackle challenging habits and routines and co-occurring medical conditions. Nurses should encourage individuals they serve to access health screenings to obtain baseline informa-tion on health status to monitor risk fac-tors or learn to self-monitor.

CONCLUSIONThrough the process of conducting

health fairs, we identified an efficient and effective way to increase individu-als’ awareness of their health status, while also offering them knowledge and support for health behavior change. We confirmed what has been showed in past studies (Citrome, Blonde, & Dam-atarca, 2005; Parks et al., 2006; Toalson, Ahmed, Hardy, & Kabinoff, 2004)—that this group frequently shows the markers for metabolic syndrome, plac-ing them at significant health risk. Al-though we have been conducting similar health screenings for several years, we continue to be surprised by the degree to which this group falls outside of the nor-mal range on many measures of risk. We

also remain impressed by the substantial efforts, courage, and commitment of many participants who have success-fully made positive lifestyle changes and those who were open to further health dialogues. This indicates the potential of this group to achieve a better quality of life and longer life span with the right information, tools, and support.

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Dr. Swarbrick is Director, Wellness Institute, Col-laborative Support Programs of New Jersey, Rutgers University, Department of Psychiatric Rehabilitation and Counseling Professions, Freehold, New Jersey; Dr. Cook is Professor and Director, Center on Mental Health Services Research and Policy, Department of Psychiatry, University of Illinois at Chicago, Chicago, Il-linois; Dr. Razzano is Associate Professor, Department of Psychiatry, University of Illinois at Chicago, and Deputy Director, Center on Mental Health Services Research and Policy, Chicago, Illinois; Mr. Yudof is Wellness Dissemination Coordinator, and Ms. Cohn is Wellness Trainer, Collaborative Support Programs of New Jersey, Freehold, New Jersey; Ms. Fitzgerald is RN, Hillside, New Jersey; Ms. Redman is Licensed Practical Nurse, Collaborative Support Programs of New Jersey, Wildwood, New Jersey; Ms. Costa is from North Bruns-wick, New Jersey; Ms. Carter is Research and Training Coordinator, Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois; Ms. Burke is Hos-pital Outreach Coordinator, Collaborative Support Programs of New Jersey, New Jersey; and Ms. Yost is Research Data Analyst, Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This research was funded by the U.S. Department of Education, National Institute on Disability and Rehabilitation Research; and the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services and Consumer Affairs Program, under Cooperative Agreement No. H133B100028. The views expressed do not reflect the policy or position of any federal agency. The authors acknowledge the contribution of the community agencies that served as the study sites and generously contributed staff time, expertise, and facilities: Moving Forward Self-Help Center (New Jersey); Thresholds Psychiatric Rehabilitation Centers, Inc. (Illinois); St. Luke’s House (Maryland); Way Station, Inc. (Maryland); Cobb and Douglas Counties Community Service Boards (Georgia); and Highland Rivers Community Service Board (Georgia).

Address correspondence to Margaret A. Swarbrick, PhD, OT, FAOTA, Director, Wellness Institute, Collaborative Support Programs of New Jersey, Rutgers University, Department of Psychiatric Rehabilitation and Counseling Professions, 8 Spring Street, Freehold, NJ 07728; e-mail: pswarbrick@cspnj.org.

Received: March 12, 2013Accepted: July 9, 2013Posted: October 8, 2013doi:10.3928/02793695-20130930-02

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